Provider Demographics
NPI:1770660839
Name:FAMILY VISION CENTER, PC
Entity type:Organization
Organization Name:FAMILY VISION CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:LAURITZEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:402-529-3558
Mailing Address - Street 1:1024 AVENUE E
Mailing Address - Street 2:P.O. BOX 367
Mailing Address - City:WISNER
Mailing Address - State:NE
Mailing Address - Zip Code:68791-2248
Mailing Address - Country:US
Mailing Address - Phone:402-529-3558
Mailing Address - Fax:
Practice Address - Street 1:1024 AVENUE E
Practice Address - Street 2:
Practice Address - City:WISNER
Practice Address - State:NE
Practice Address - Zip Code:68791-2248
Practice Address - Country:US
Practice Address - Phone:402-529-3558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE767261Q00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE25136OtherWISNER COVENTRY PAYOR ID
NE8422OtherWISNER MIDLANDS CHOICE
NE7748OtherWISNER BLUE CROSS
NE25136OtherWISNER COVENTRY PAYOR ID
NE092155Medicare PIN
NE8422OtherWISNER MIDLANDS CHOICE
NE25136OtherWISNER COVENTRY PAYOR ID